Mental Health Care

In Search of a Common Language

Brant Fries began his research odyssey 25 years ago, when he and his team built their first Resident
Assessment Instrument, or RAI. That instrument was designed to give nursing homes
a "common language" with which to assess the caregiving needs of residents.

A professor of health management and policy and research professor in the U-M Institute of Gerontology, Fries went on to develop assessment instruments for vulnerable populations in a broad
variety of institutional and non-institutional settings. The international company
over which he now presides, interRAI—a 33-nation consortium—has created assessment instruments for a broad spectrum of
needs, including home care, acute and post-acute care, assisted living, correctional
facilities, and children's mental health. Twenty U.S. states and multiple nations
and provinces have adopted interRAI instruments.

"Our goal is to try to be the standard for assessment in all vulnerable populations
around the world," Fries says. InterRAI is currently working with New York State to
design developmental disability assessment systems, and with Israel to create instruments
to assess elderly persons with developmental disabilities. Fries and his team are
also partnering with the World Health Organization to provide health and mental health
assessment systems for developing nations, where resources are considerably limited,
and mental health care is an issue of growing concern.

"The problem with mental health is that there are no standard instruments, no standard
terminology," Fries explains. "Caregivers need to know who's been caring for a person,
whether that care has been formal or informal, and the history of a person's problems.
They need to know about functionality and behavioral issues."

The information interRAI's instruments convey is, in some ways, the equivalent of
the "elevator speech," he says. "It gives caregivers an immediate sense of what they
need to know about a person in order to provide appropriate care."

Mental Health Parity and Infrastructure

Last fall, the federal Mental Health Parity and Addiction Equity Act of 2008 went
into effect, requiring group health plans and health insurance providers to ensure
that limits on benefits for mental health and substance abuse treatments be no lower
than limits on medical and surgical care. With mental health and substance abuse care
now part of essential services, Kyle Grazier, the Richard Carl Jelinek Professor of Health Services Management and Policy, is
working to make sure the health system's infrastructure can handle the projected rise
in demand for services.

In collaboration with the Robert Wood Johnson Foundation and other organizations,
Grazier is developing new policies and models aimed at improving efficiencies in mental
health screening and easing patient access to specialty services—both in primary care
settings (the source of most mental health services in the U.S.) and in ambulatory
settings funded by Medicare and Medicaid. She and her colleagues are also working
to facilitate the delivery of mental health services to vulnerable populations.

In related projects, Grazier is working to improve access to health care for newly
released prison populations in the U.S.—many of whom have mental health issues. She's
also partnering with state officials in Colorado, as well as with a group of developmentally
disabled individuals, to identify and meet the health needs of the developmentally
disabled in that state.

Stress, Health, and the Epigenome

The associations between low socioeconomic status and poor health outcomes are well
documented, but researchers have yet to identify the biological mechanisms that underpin
those associations. Scientists hypothesize that changes to the epigenome—the chemical
compounds that mark or modify the genome and influence gene expression—may provide
a link between the social environment and the risk of disease.

Belinda Needham, a research assistant professor of epidemiology and a sociologist by training, believes
it's "vital to establish whether there's a causal relationship between socioeconomic
status and health." Toward that end, she's collaborating on a study aimed at determining
whether low socioeconomic status is linked to increased DNA methylation—a key process
by which epigenetic change occurs.

Using a population-based sample of 1,264 white, African-American, and Hispanic participants
ages 55–94, Needham and her colleagues are examining a subset of 18 genes related
to stress reactivity and immune function. To date they've found that low socioeconomic
status is, in general, associated with increased methylation in several genes. Individuals
who've experienced persistently low socioeconomic status stand out most distinctly
from a comparison group of people with persistently high socioeconomic status. Interestingly,
says Needham, indivi- duals who have experienced upward social mobility from childhood
to adulthood are much less distinct from the comparison group.

"This suggests that the negative consequences of low childhood socioeconomic status
for adult health can potentially be ameliorated through increased educational attainment,"
Needham says, noting that this research has implications for education policy. "It
makes upward mobility that much harder when we don't have good support for state institutions
of higher learning."

Better Decision-Making

With advancing health information technology, people often have direct access to their
medical test results. But how can we ensure that they understand and can use such
results to make health care decisions? Brian Zikmund-Fisher, assistant professor of health behavior and health education, is examining how best
to inform people with diabetes of their Hemoglobin A1c values—a method for determining
blood sugar control. Zikmund-Fisher hopes to find the best means for disseminating
this data so that it's meaningful to individuals. Eventually he hopes to develop and
introduce a test results "display generator" application that people can access via
a freely available website. —Rachel Ruderman